Abstract
The pure skin perforator (PSP) flap is a recognized option for hand reconstruction because of its thinness and pliability. Conventional planning involves high-frequency color Doppler ultrasonography to locate perforators, followed by subdermal elevation and distal-to-proximal pedicle dissection. However, access to high-frequency ultrasound remains limited in certain institutions, even in cases requiring extensive PSP flaps. This report presented a technical adaptation for such circumstances. We report on a 70-year-old man with a 12.5 × 10 cm soft-tissue defect from the palmar index metacarpophalangeal joint to the ulnar dorsal hand after traumatic infection, debridement, and index finger amputation. Without high-frequency ultrasound, we designed a 15 × 10 cm PSP flap centered on the superficial branch of the right superficial circumflex iliac artery (SCIA). Intraoperatively, perfusion originated from perforators of the SCIA deep branch rather than the superficial branch. To accommodate this, the proper palmar digital artery (PPDA) of the small finger was divided, and end-to-end anastomoses were performed: proximal PPDA to SCIA deep branch and distal PPDA to SCIA superficial branch. No complications or contractures were observed at the 6-month follow-up. This case demonstrates a practical intraoperative strategy for large dorsal hand reconstruction with SCIA-based PSP flaps when high-resolution imaging is unavailable. Our experience suggests that anatomical variability of SCIA perforators can be managed intraoperatively, and flap design adapted to resource-limited settings warrants further study.